Telemedicine in healthcare access during the covid-19 pandemic: a scoping review

ABSTRACT OBJECTIVE Mapping the role of telemedicine in the health access of patients with chronic diseases in continuous care actions (except for covid-19) during the pandemic. METHODS This is a scoping review, with an adapted version of the Prisma-Scr methodology and using the Population (patients with chronic diseases), Concept (telemedicine as a health access tool) and Context (covid-19 pandemic) strategy. We searched through the following databases: PubMed, Scopus, Embase, Web of Science, Lilacs and SciELO, resulting in 18 articles at the end of the review. We used the technological, sociocultural and assistance analysis dimensions. RESULTS Eighty-eight percent of the analyzed papers posited that telemedicine use to provide care increased during the pandemic. We identified that this use was positively related to the reduction of complications and the absence of physical displacement for care, expanding it to rural areas. Important barriers were presented, most importantly the digital exclusion, language sociocultural barriers, and inaccessibility to technological instruments for disabled people. CONCLUSIONS Innovation in care arrangements calls attention to how living labor is important to produce healthcare, using various technologies, and reveals tensions caused by the forces acting on healthcare micro politics. We conclude that, despite important barriers, telemedicine contributed to the care of chronic patients during the covid-19 pandemic.


INTRODUCTION
The organization and preparation of international health systems changed after the declaration of the Public Health Emergency of International Concern (PHEIC) issued by the World Health Organization (WHO) in January, 2020, due to the global outbreak of coronavirus 1 . Recommendations included supporting fragile health systems, developing immunizers, as well as therapeutic strategies, combating misinformation, strengthening diagnostic mechanisms with an emphasis nor only on isolation, but also transmission prevention, and stimulating the sharing of scientific knowledge and international cooperation.
The first months of viral contamination posed enormous challenges to treating infected patients, overstretching health systems and demanding health services, such as hospitals and outpatient clinics, to change their routine immediately. The concentration of efforts in treating cases of severe acute respiratory syndrome (SARS) caused postponements and cancellation of face-to-face health actions to protect patients from exposure to the virus 2-5 .
The high case incidence during the pandemic created new strains of SARS-CoV-2, collapsing many health systems, which made it urgent to resume the care of non-covid patients and the chronically ill, offering continuous care 6,7 ;. The need to reorganize services, tasks and reinvent ways of doing health was strongly evidenced and considered fundamental 8 . Thus, the technology use gained global prominence in health actions, work and educational activities, as well as to financial and commercial transactions 2 .
The first pandemic confronting reports indicate the monitoring of suspected and confirmed cases by phone or smartphone application, as well as the deployment of telemedicine tools 2 to guide the general population. These tools served as an initial screening to measure the severity of cases, helping to guide the users' search for health services, with the objective of prioritizing demand. Countries such as France and the United Kingdom implemented telemedicine actions early, ensuring the compensation of the procedures through the National Health Insurance 9 and using voice and video resources that also increased the self-care of patients with respiratory diseases 10 .
Even before the emergence of the new coronavirus, several factors contributed to the growth of telemedicine, such as technological advances in communication and information. This a result of the increasing use of high-speed internet and the rise in the number of files in electronic medical records in health services 11 . For Cordioli 12 , telemedicine comprises the service provision related to healthcare in cases where distance is a critical factor, and can be used both for urgent consultations, in the context of covid-19, and routine appointments, given the need of overcoming access barriers, ensuring data protection and providing alternatives to physical examination.
In this context, telemedicine (or telehealth) has different applications, such as teleconsultation, telemonitoring, teleregulation, teleorientation, among others 13 . Currently, the term telemedicine is associated with the terms telehealth and e-Health, with imprecise conceptual distinctions 14 . During the expanded literature search, it was possible to distinguish the use of telemedicine in two large groups: the use of technology as a care arrangement for infected patients and the use of technology as a care arrangement for non-covid patients, a possibility for which this study is interested, regarding access and continuity of care.
This scoping review aims at mapping the contribution of telemedicine to health access of patients with chronic diseases in continuous care actions -non-covid -in the context of the pandemic. The chosen methodology makes it possible to identify the existing literature on the subject, providing elements to analyze the use of telemedicine in the context of covid-19, recognize innovations and new care arrangements, and locate barriers to The search of scientific papers which integrated the review occurred from the search command-line built with the Health Science Descriptors -DeCs (Telemedicine AND Chronic Diseases AND COVID-19 AND Access to health care), including the period from March, 2020 to March, 2022 for publications in English, followed by double-blind evaluation for the scope assessment stages. All types of scientific papers were included, as well as scientific reviews, without geographical limitation and regardless of publication type. Regarding the results shown in Figure 1, title and keywords were considered in the first analysis and initially included n = 342 papers, 32.16% of which were from PubMed, which retrieved the highest number of results, followed by Web of Science (24.26%) and Scopus (23.39%). The papers were saved in the reference management software Endnote and processed by the platform Rayyan.
In these results, the following exclusion criteria were applied: articles which did not address the use of telemedicine, directed to populations that were not formed by chronic patients, outside the covid-19 pandemic period, discussing specialties that do not fit the chronic criterion and addressing issues related to mental health (n = 98 papers). In the Rayyan platform, duplicates were removed (n = 80 papers) and articles from additional sources were inserted (n = 2 papers), in addition to performing a second double-blind evaluation of the previous results, considering title and abstract (n = 166 papers). At this stage, the inclusion conflicts (n = 11 papers) were sent to new reviewers in double-blind evaluation for final decision, in which n = 5 papers were included.
The analysis included n = 49 papers for full content evaluation; from which, only n = 18 papers were selected for the scope study, because they present elements that can help us answer the research question. We analyzed the following dimensions: technological (type of technology used, resources used, identified innovations), sociocultural (age, income, language) and assistance (type of chronic disease, professionals involved in care, technical and ethical limitations). After extracting the results, they were categorized and discussed by the authors.

RESULTS
The results identified in the scope of the 18 selected articles are presented in the Chart, containing the characterization of the studies (place of study, publication year, authors, language, description of the study, type of chronic disease studied and type of digital health care technology used). The identified conclusions are presented in Figure 2, an Analytical Diagram including aspects of the analysis carried out by the authors, which will be presented in the discussion.
All papers were published in English, but differed in geographical distribution: n = 10 of the papers were produced in the United States 20-29 and n = 1 was a study performed in Latin America 30 . Southeast Asia, on the other hand, was cited in n = 1 paper 31 , and Italy 32 , the United Kingdom 33 , Germany 34 , Canada 35 and Turkey 36 also contributed with n = 1 paper each. We identified only one study with a systematic review methodology, which mentioned having considered studies from five regions of the World Health Organization (WHO), with a predominance of articles from Europe 37 .
As for the publication date of the studies, 77% of them were published in 2021, while 16% correspond to the first year of the covid-19 pandemic. In addition, only n = 1 paper was published more recently, in 2022. Regarding the type of study and data source, 44% of the studies are quantitative, with primary data sources and collected through questionnaires applied by telephone or via the internet. Only n = 4 studies used qualitative methods, and n = 2 papers presented narratives as data source; besides, there were systematic reviews, evaluation and mixed methods papers, each of them corresponding to 11% of the total.  Haynes, S. C. and Kompala, T. and Neinstein, A. and Rosenthal, J. and Crossen, S.

United States
Identify patient-level factors associated with the adoption of telemedicine for subspecialty diabetes care during the pandemic.

Perceptions of Telehealth vs In-Person Visits Among Older Adults
With Advanced Kidney Disease, Care Partners, and Clinicians 23 2021 Ladin, K. and Porteny, T. and Perugini, J. M. and Gonzales, K. M. and Aufort, K. E. and Levine, S. K. and Wong, J. B. and Isakova, T. and Rifkin, D. and Gordon, E. J. and Rossi, A. and Koch-Weser, S. and Weiner, D. E.

United States
Identify patient, care partner and nephrologist perceptions of patient centralization, benefits and disadvantages of telehealth compared to face-to-face consultations. Investigate the effects of a supervised telerehabilitation program compared to a conventional supervised pulmonary rehabilitation program.

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Concerning the type of digital health care technology used, 44% of the studies referred to the use of telemedicine [21][22][23]25,27,31,36 . Telehealth was cited in 27% of the analyzed articles 20,[27][28][29]37 , telerehabilitation in 11% 25,32 and teleneurology 24 , video consultation 34 and remote monitoring 35 accounted for 15% of the total. It bears noticing that we mainly considered the technology cited in the study, since some authors used more than one technology.

Chart. Articles included in this scoping review. Continuation
Where Virtual Care Was Already a Reality: Experiences of a Nationwide Telehealth Service Provider During the COVID-19 Pandemic 27 2020 Uscher-Pines, L. and Thompson, J. and Taylor, P. and Dean, K. and Yuan, T. and Tong, I. and Mehrotra, A.

United States
Description of the use of telehealth services provided by a well-known company in the United States before and during the covid-19 pandemic.
Analysis of the number of virtual visits, their reasons and modifications observed over time. Chronic respiratory diseases represented 50% of the articles, being the disease group that relied the most on telemedicine, especially chronic obstructive pulmonary disease (COPD) (n = 4 papers) and cystic fibrosis (n = 2 papers). Only 22% of the articles did not delimit the type of chronic disease, characterizing them as chronic diseases in general. We also included studies on diabetes, cancer and chronic neurological diseases, which corresponded to 15% of the total. Half of the identified articles presented the increased use of telemedicine for the care of patients with chronic diseases during the covid-19 pandemic as the main result 20,23-25,27-29,31,37 .
The beginning of telemedicine activities was also reported In n = 3 papers 21,26,37 .
We identified other results related to the use of telemedicine in the healthcare of chronic patients, such as the improvement of indicators 33 decrease in complications 36 , increased patient receptivity 29 , video consultations with concrete clinical recommendations / medicine change 34 and identification of benefits in pre-and postoperative care 35 . On the other hand, there were unfavorable results regarding the use of telemedicine, such as the identification of patients' inability to use 26 , lower patient engagement 29 , problems with emotional responses and approach to complex issues 29 and access difficulty, including to electronically prescribed medicines 30 .
The innovations incorporated in the scope of care performed by telemedicine presented structural and assistance characteristics. Among the structural innovations, sending equipment to monitor and measure vital signs (blood pressure measuring device, glucometer, pulse oximeter, home spirometer, among others) to the patients was the most common arrangement, being present in 27% of the studies 20,31,34-36 .

Carriers of chronic diseases Funding and regulation Telemedicine
Blood collection at home 20 , deployment of drive-thru labs 19 and the delivery of medicine at home 31,36 were also listed. Other structural arrangements are related to the offered technology itself, such as the availability of e-learning platforms to train patients 33 and the possibility of using multiple platforms 24 enabling access for those who have less technological aptitude, in addition to partnerships with University Hospitals and medical schools 31 .
The technological arrangements of care identified as assistance are those invented, adapted or used for the care performed by the health professional or the care chain, through digital technologies. In this sense, it is possible to list prescriptions online 30,31,36 , use telemedicine for comprehensive patient care 28 , including pre-and postoperative care 37 , acting in the regulation and management of complex cases 31 , adoption of detailed pre-consultation protocols 28 and hybrid care protocols, including face-to-face and online consultations, when necessary 23,26 , and the service performed by multiprofessional team 25 .
Regarding access to health services through telemedicine for patients with chronic diseases during the covid-19 pandemic, 88% of the articles reported access barriers to the use of telemedicine. These were: technological barriers resulting from digital exclusion 20,23,[26][27][28][29][30][32][33][34][35][36][37] , internet access difficulties 23,28,33,35 , connection problems 36 sociocultural barriers (low purchasing power being the main one) 23,27,36,37 , related to language 23,29 , age 20,34 , disability 29 , the type of health insurance and the telemedicine funding, as well as the assistance access (22%). Among the most important are the limitation in the physical examination of the patient 25,28 , lack of professionals 26 and aspects regarding specifically the disease or age group, such as hearing problems 23 . All these barriers are mainly related to vulnerable populations, including refugee and immigrant groups 20 .
In addition, aspects that facilitate patients' access to health care through telemedicine -such as expanding the offer to residents in remote or rural areas (16%) 24,31 , factors related to saving time and resources with commuting 24 (11%) and the increased involvement of family members and caregivers 20 (5%) -are pointed out as benefits of the implementation of the remote system. With regard to the future of telemedicine in health systems, the recommendation for the development of guidelines and protocols enabling safe and effective service provision with good digital infrastructure is identified in 83% of studies.

DISCUSSION
From the mapping and analysis of the data provided by the literature used in this review, we identified the exponential increase in the use of telemedicine and other remote care modalities during the covid-19 pandemic aimed at the care of chronic patients in continuous care. We know that this is an even more comprehensive concept, if we consider here the use of telemedicine forms excluded by the adopted methodological criteria.
After the organization and analysis of the results, we identified three dimensions: trends in telemedicine, innovations in care and access barriers, as shown in Figure 2.

Trends in Telemedicine
The scope of the selected articles highlights the predominance of studies produced in the United States, especially in scenarios where telemedicine had already been used before the pandemic. The availability of technological structure made it possible to quickly implement 25,32-34 these procedures in the USA. In addition, the incorporation of telemedicine in the list of reimbursable procedures by US health plans has served as an incentive since the beginning of the pandemic 20,21 . A study involving a large American telehealth provider also highlighted the increase in demand for care due to chronic diseases and mental health issues, surpassing the search for care motivated by the coronavirus 27 .
On the other hand, in many other locations, such as in China, latent structures gained visibility and could be used in the care of patients because of the health emergency. The authors argue that the structures unveiled in the pandemic should be kept after the mitigation of cases and control of the situation 38 .
We also observed a predominance of papers on the use of telemedicine aimed at the care of patients with chronic respiratory diseases (CRD), a condition that appears among the main causes of morbidity and mortality worldwide. Commonly found, COPD and asthma are among the 20 diseases that disable the most amount of people on a global scale 39 . The use of telemedicine in pulmonology is not recent: Zamith and Gomes 40 identified studies performed since 1993 containing the association of words "telemedicine" and "lung". Additionally, the shortage of professionals specialized in pulmonology had already been observed years before the pandemic, and studies that pointed to the use of technological arrangements that could contribute to improving this scenario and guarantee patient access had already been published, such as the described experiences of matrix support and shared care in pulmonology 41,42 .
Besides, the increased demand caused by the pandemic and the potential risk to patients with CRD are also points that contribute to the understanding of the predominance of studies in Pulmonology. Pulmonary telerehabilitation, on the other hand, showed promising results regarding the progression of exercises and improvement of disease indicators 24 , although there are limitations identified in the access of patients 27 .
In Italy, patients with COPD reported receiving twice as many telemedicine visits from pulmonologists as from family doctors 32 . The possibility of providing self-monitoring instruments and the good results the use of equipment at home have demonstrated seem to be factors that give advantages in the monitoring of chronic respiratory diseases, when talking about advances in telemedicine 34 .

Innovations in Care
The social distancing recommendation adopted by several countries during the pandemic had great adherence among patients with chronic diseases and accentuated difficulties in accessing care, warning about the risk of increased morbidity, disability and avoidable mortality 43 . Brazilian authors emphasize that it is necessary to discuss policies and identify strategies that allow continuity of care, minimizing interruptions and adapting to the new scenario, taking risks of reinforcing or widening inequalities 44,45 .
Based on the conjuncture established by covid-19, the first publications 46,47 already evidenced the urgency in identifying possibilities for care, encouraging innovations, in an attempt to circumvent the imposed difficulties. Based on the results, telemedicine, generally, presented itself as one of the most important of these innovations, offering powerful mechanisms to act in a scenario of fast-paced contamination 11,21,31,48,49 . Although it was not exactly a new arrangement, telemedicine contributed to the diversification of care, using characteristics such as versatility and broad capacity to reach different populations and health needs. The described innovations demonstrated the importance of offering patient-centered, multilevel, multidisciplinary and continuous care 32 .
The identification of innovative structural arrangements and innovative care arrangements alludes, although in a rudimentary way, to the models of care production and the importance of living labor in the process of care production 50 . Thus, considering that certain arrangements relied more heavily on hegemonic instruments, tools and knowledge -also known as "Hard technologies " and "Soft-hard Technologies" -while others were built based on relational aspects, produced in the overlap between health professionals and the patient -known as "Soft technologies" 51 . From this perspective, we identified relevant aspects in each one of them. The innovative structural arrangements, represented here by sending equipment to the patients' homes, online prescriptions, drive thru laboratories, among others, raise the issue of telemedicine regulation and funding, inside and outside Brazil. Aspects such as differences in nomenclature and scope, security and protection of patient data, and compensation of services often represent obstacles that must be overcome through defining specific policies and broadly discussing the topic 45,52 .
In Brazil, the regulation in health had been discussed and was moving forward in the On the other hand, innovative care arrangements, in turn, portray aspects of the relationships and micro politics of health services 56 . The results found in this review express the tensions experienced in the daily life of services, from bureaucracy to the freedom experienced by health professionals, rooting from unknown situations. The professional performance took place in adverse conditions, outside the comfort zone and with the need to adapt to the unusual scenario. These circumstances made everyday tasks more flexible and enabled the professionals to assume new roles 8 .
In many cases, since there was little regulation and/or a character of exception leveraged by the pandemic, new possibilities of care have emerged, in addition to experiments and incorporation of new protocols 28 . The "temporal window of opportunities" 57 , which opened due to the health crisis, brings complex existential challenges to Public Health in the "post-" pandemic moment. Decentralized caring and integrative practices 42 are important elements in the analysis of the response to the pandemic.
Finally, the results showed that telemedicine practices have good acceptance rates, both among patients and families and among health professionals and managers 20 . On the other hand, they require in-depth studies regarding cost-effectiveness, quality and user satisfaction; however, the unavailability of data weakens their advancement, regulation, financing and use 58 .

Access Barriers
The trends and innovations arising from the use of telemedicine for the care of chronically ill patients during the pandemic identified in this review are relevant and offer clues both for policy formulation and for the development of new studies. However, regarding access to health care for the chronically ill using telemedicine, most of the papers included in this review point to numerous barriers [20][21][22][23][25][26][27][28][29][30][31][32][33][34][35][36][37] . Observing that telemedicine has expanded its borders and is consolidating itself as a care arrangement(s) for chronic diseases 59 should not be dissociated from the dimension of access and, especially, from the identified barriers. The formulation and implementation of health policies based on technology-mediated care, such as telemedicine and its variations, can both contribute to reducing barriers in health access and highlight inequalities that may compromise the universality of access to health services.
Analyzing the effect that the pandemic has produced on access to health is one of the main current challenges for building resilient health systems. For some authors 60 , the resilience of health systems goes beyond the "fulfillment of the right to health" and encompasses social and economic activities, reproducing the experience of the pandemic. Therefore, early identification of the barriers caused by the use of telemedicine in the health care of chronic patients can prevent the increase of inequities in access to care. In addition, it is essential to include the patient's dimension, with its diagnostic specificities, in the formulation of policies and protocols 21 .
Although the main challenge regarding access is linked to digital illiteracy (or digital exclusion), the gap evidenced by technology reflects social and health inequalities of the population, whose reduction should guide the construction of quality health systems, with guaranteed access and equity.
However, we also identified factors that can help the patient's access 20,24,25,31 , and they can serve as a starting point for policymaking and service implementation. The improvement of the use of digital technologies is central to this discussion and demands political and management efforts in digital infrastructure investment 24,28,31,37 .
We concluded that the increase in telemedicine throughout the covid-19 pandemic presented innovative technological arrangements that, at the same time, collaborated with the expansion of access and with the implementation of this modality of care in the daily life of Health Services. However, issues related to digital exclusion and sociocultural and care conditions were pointed out as access barriers to the use of telemedicine that must be overcome in order to expand, in fact, its use value, caregiver potential and innovation in health systems.
The implementation of specific policies and the elaboration of protocols that guide the work of professionals, particularly for chronic conditions, are important recommendations for incorporating telemedicine as a safe, accessible and care-producing technology for health systems and services around the world.